1083606677 NPI number — T.K THOMAS MD PC

Table of content: (NPI 1083606677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083606677 NPI number — T.K THOMAS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T.K THOMAS MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083606677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
842 MOORLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE POINTE WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-1129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-776-3340
Provider Business Mailing Address Fax Number:
586-778-6460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22480 KELLY RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
EASTPOINTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48021-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-776-3340
Provider Business Practice Location Address Fax Number:
586-778-6460
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
586-776-3340

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301040256 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 71020001500026 . This is a "BC BS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1361698 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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